Sampson Regional Medical Center - Blood Drive Request Form

Patient Portal Contact Careers (910) 592-8511

Thank you for your interest in SampsonRMC's Blood Donor Services. Please complete and submit the form below. A staff member will contact you by phone or email to schedule a time for your blood drive.

Host Organization Name:

First Name: *

Last Name: *

Address:

City:

State:

Zip Code:

Phone Number:

Email:

Preferred Blood Drive Time:

Morning
Afternoon
Evening

Preferred Blood Drive Day:

Monday
Tuesday
Wednesday
Thursday

What is the best way to reach you?

Phone
Email